ÆäÀÌÁö À̹ÌÁö
PDF
ePub

15. Positive changes in general.-The positive diagnosis of preg nancy depends on the demonstration of the existence of the products of conception. In the normal cases the presence of the fetus can usually be proved after the fifth month by what are called the positive signs of pregnancy; namely:

1. Palpation of the fetal outline. 2. Feeling the fetal movements. 3. Hearing the fetal heart-beats.

16. Fetal outline. In the later half of the pregnancy it is usually possible, either by abdominal or vaginal palpation, to feel the parts of the fetus, and map out its outline in the abdominal cavity. Other masses in the abdomen may be mistaken for isolated parts of the child, but when the whole outline-head, breach, back, and extremities are all clearly felt, as is not infrequently possible, especially near term, there is no other condition which can be mistaken for pregnancy.

17. Passive fetal movements,-ballottement.- From the fourth to the eighth month, on bimanual palpation of the uterus, the fetus can be felt floating in the liquor amnii; and when knocked away from the palpating finger in the vagina, by a quick movement of the wrist, and then allowed to resume its former position, the fetus will be felt to drop back and strike the finger again. This sign, called ballottement, may also be obtained in the later months, with the two hands on the abdomen, when the fetus will be felt to sink on the quick pressure, and return against the hand again. The fetus must be differentiated, on the one hand, from a stone in the bladder full of urine, and, on the other hand, from a pedunculated mass in the abdomen distended with ascitic fluid; but this distinction is not difficult if all the possibilities are kept in mind.

18. Active fetal movements. In addition to these passive movements of the fetus, after the fifth month the active movements of the child can usually be felt as it kicks against the abdominal wall. These movements, too, are at times thought to be felt when really the mother or the examiner is feeling the muscular movements of the mother's abdomen or the peristaltic movements inside of the abdomen. But so long as there is any question on the point, the sign cannot be said to have been elicited.

19. Fetal heart sounds,-umbilical souffle, et cetera. In the fifth month, too, the characteristic, well-established sign of the fetal heart-beat becomes audible; best known, perhaps, because most easily determined; as it needs little skill to hear the distant tic-tac of the

fetal heart, and count its beats, about one hundred and forty per minute. There are several other sounds, however, for which it should not be mistaken. The umbilical souffle, a soft, whistling sound, synchronous with the fetal heart, and probably due to obstruction in the circulation in the umbilical cord, therefore equally characteristic of pregnancy; the lub-dup of the maternal heart, which normally occurs about seventy-two times per minute, hence, easily distinguished from the more rapidly beating fetal heart; the uterine souffle, a soft, blowing sound, synchronous with the maternal heart, heard often during pregnancy and in some other uterine conditions; the bruits sometimes heard over the abdomen in some blood and vascular diseases of the mother, and synchronous with the mother's pulse; and the irregular sounds caused by the fetal movements, peristalsis in the mother's abdomen, et cetera, which could scarcely be confounded with the rhythmical fetal heart sounds.

20. Summary of positive signs. When any one of these positive signs is clearly obtained, the diagnosis of pregnancy is established beyond doubt. But the active fetal movements and the fetal heart sounds are, of course, absent after death of the fetus in utero, so that the absence of these signs can not exclude pregnancy, and the palpation of the fetal parts might be the only one of these positive signs present in a case where there is no doubt of the existence of a fetus in utero.

21. Abnormal pregnancies in general. In the not uncommon extrauterine pregnancies, and in other abnormal products of conception, where the fetus inside the uterus is represented by a bloody or a hydatidiform mole, the absence of a fetus from the uterus does not preclude the possibility of pregnancy. In fact, all the positive signs of pregnancy may be absent after the period when they are regularly found, and yet prove merely the absence of a normal pregnancy.

22. Hydatidiform moles, etc.- In the cases of degeneration of the fetus, and the formation of a fleshy, a bloody, or a hydatidiform mole (when, of course, the positive signs are all absent), the diagnosis depends on the demonstration of the existence of these peculiar products of conception. That diagnosis can be made only with certainty by the gross or microscopical examination of these products in whole or in part, taken from the uterus.

23. Extrauterine pregnancy.- In the cases of extrauterine pregnancy, where the fetus has its nidus outside of the uterine cavity, the normal signs of pregnancy, due to the changes in the size of the uterus, are greatly modified; the maximum size being that of about

two or three months pregnancy under normal conditions. Those due to the changes in the signs of the cervix and vagina are not so regularly developed; but the breast changes are developed in their usual course. In the later months of the pregnancy, if not disturbed, it is possible to identify the fetal parts and hear the fetal heart sounds in the abdominal cavity outside of the uterus. But, as a rule, these abnormal cases terminate before that period of development. In the cases terminating before the time for labor, if the mother survive, and no medical attention be given, retrogressive changes may take place. In these early-ended cases, absolute proof of the pregnancy could be obtained only through a surgical operation, or the examination of the decidua, if it be expelled from the uterus, though the diagnosis might be perfectly satisfactory to the medical man without such evidence. An extremely interesting case in connection with these extrauterine pregnancies is described by Winter.11 A woman, after a single abortion, remained sterile for eight years. Then there came a period of suppression of the menses for five months till she felt the child kicking within her, and an increasing size of her abdomen. In the ninth month development ceased and retrogression began and continued for five years. the end of that time she was operated upon for abdominal symptoms and the previous diagnosis of extra-uterine pregnancy confirmed by finding the remains of the fetus and placenta. This shows the possibility of pregnancy in an a priori unlikely case, where the diag nosis was made in spite of the empty uterus, and the passing of the time for labor without the birth of the child; and yet the operation, five years later, left no doubt of the pregnancy.

At

24. Summary. To summarize, we see that the positive diagnosis of existing pregnancy can be made only in the second half, and then by the demonstration of the existence of the fetus by the three positive signs: the fetal outline, the fetal movements, and the fetal heart-beats; that in the early months the diagnosis may be made. with great probability, based on the presumptive signs; the most important of which are the rhythmical contractions of the uterus, Hegar's sign, and the changes in the breasts; that the refutal of a charge of pregnancy cannot be made even if there is no fetus in the uterus, because the possibilities of an extrauterine pregnancy or uterine mole must be excluded. And this can be proved only by the examination of the uterine contents or the nidus of the extrauterine fetus.

"Winter, Gynäkol. Diag., p. 94.

25. Post-mortem diagnosis. After death the diagnosis can be determined beyond question, if the pregnancy has advanced even a few days, by the finding of the products of conception in ovary, tube, abdominal cavity, or uterus. Though the difficulty increases the shorter the duration of pregnancy.

CHAPTER II.

DIAGNOSIS OF PREVIOUS PREGNANCY.

I. AFTER EARLY ABORTIONS AND ABNORMAL CASES. 26. Signs in objects discharged from uterus. 27. Signs remaining in woman.

II. AFTER SECOND-HALF ABORTION AND LABOR AT TERM. 28. In general.

29. Temporary signs in general.

30. Breasts.

31. Parturient canal.

32. Uterus.

33. Lochia.

34. Permanent signs in general.

35. Parturient canal.

III. IN POST-MORTEM EXAMINATIONS.

36. Temporary signs in general.

37. Corpus luteum.

38. Permanent signs; size of uterus.

39. Uterine walls.

IV. MENSTRUATION VERSUS PREGNANCY.

40. In general.

V. NUMBER OF PREGNANCIES, AND DATE OF DELIVERY.

41. Number of pregnancies.

42. Date of delivery.

VI. FEIGNED DELIVERY.

43. In general.

I. AFTER EARLY ABORTIONS AND ABNORMAL CASES.

26. Signs in objects discharged from uterus. The question as to whether or not a woman has ever been pregnant deserves the same attention as that as to whether she is pregnant at the time of examination. But the marks of the pregnancy do not always remain to settle the question. If the fruits of conception can be examined, that will prove the diagnosis; but unless seen at the time of emptying the uterus, these products are generally wanting. In the objects discharged from the uterus, we must distinguish as fruits of conception the fetus and the moles; and exclude blood clots, polypi, and the membrane of membranous dysmenorrhea. The fetus is easily recog

« ÀÌÀü°è¼Ó »